Healthcare Provider Details

I. General information

NPI: 1285285973
Provider Name (Legal Business Name): TERRACEDAR SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9317 MADINA PKWY
FORT WAYNE IN
46825-1134
US

IV. Provider business mailing address

9317 MADINA PKWY
FORT WAYNE IN
46825-1134
US

V. Phone/Fax

Practice location:
  • Phone: 260-310-9599
  • Fax:
Mailing address:
  • Phone: 260-310-9599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. MONCHELLE DENISE DAVIS
Title or Position: CEO/HABILITATION SPECIALIST
Credential:
Phone: 260-310-9599